Bonding veneers to support new excursive movements

A clinical case by our Community member Dr Edward Li

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

Creating new anatomical landmarks that can predictably support new anterior and lateral guidance is necessary when providing significant smile transformations.

From the new smile design, choice in palatal/lingual finishing line, macro surface preparation, ceramic choice, bonding protocols and composite choice are all factors that come together to create long lasting and durable results that can support healthy functioning occlusion.

It is common for patients suitable and seeking extensive treatment transformations with porcelain veneers to present with signs of tooth-wear, reduced clinical crown heights and in particular, the bluntening of functional cusps on the cuspid and bicuspids. It is incredibly limiting to work and design to match existing clinical crown heights, vertical dimension and within the same functional envelopes. To decide case by case which parameters are healthy to maintain and operate within, and which parameters require redesigning and implementation into the new anatomy for success across various areas such as aesthetics, occlusal function, and the longevity of restorative materials.

This case documents walks through many of these internal questions ask oneself and aim to explore the thought processes of each step.

styleitaliano style italiano bonding veneers indirect anterior restoration initial situation

Fig.1
After completing orthodontic treatment, the resulting arch-form and tooth positioning offered an excellent foundation. The patient sought the restorative phase to address tooth-wear asymmetry, tooth coloration, and white patches on the upper labial segment. Prioritizing minimal maintenance and longevity led to considering porcelain veneers. In most cases, the preference was for Lithium Disilicate (e.max), the material my ceramist Lukas is highly skilled in. Recognizing the wear asymmetry, and the need to establish new functioning cusp tips on the canines and premolars, smile design wax-up and clinical protocols will duly account for these factors.

styleitaliano style italiano bonding veneers indirect anterior restoration initial situation

Fig.2
A view of the upper anterior teeth corrected to match the patient’s eye level showing significant differences in the cuspid and bicuspid. When viewing white patches, the use of Icon resin infiltration was always considered, however in this case, the use of Li2O5Si2 nullifies the need to camouflage this substrate when whitening and the enamel preparations would largely overcome this. This is because the patient wanted to change the form, appearance, and overall smile using porcelain veneers.

styleitaliano style italiano bonding veneers indirect anterior restoration analogue wax-up

Fig.3
An analogue wax-up is crafted to visualize achievable symmetry through an additive approach. This design is created over the existing teeth. Using the Artex articulator and the No-Plast mounting jigs, designing and testing the lateral guidance for the newly built right cuspid and bicuspid is straightforward. In cases involving veneers and a history of wear, distributing forces and load to a group function between the canine, first premolar, and second premolar is preferred.

styleitaliano style italiano bonding veneers indirect anterior restoration a trial smile appointment

Fig.4
A trial smile appointment is crucial to gather the patient’s perspective and for clinicians to build confidence in the planned procedures. With the use of DMG Luxatemp Star, it consistently represents the colors intended to communicate with the patient. B1 was initially chosen for visualization, but it was learned that the patient desired a slightly whiter shade.

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styleitaliano style italiano bonding veneers indirect anterior restoration extra-oral view of the trial smile

Fig.5
Extra-oral view of the trial smile. The trial was successful in addressing the asymmetrical wear and quite closely balanced the left and right. The patient liked the slightly squarer silhouette and thus, the foundation for the porcelain veneers was ready for the ceramist to use as a starting point.

styleitaliano style italiano bonding veneers indirect anterior restoration whitening

Fig.6
The patient underwent whitening with a course of 10% carbamide peroxide (CP) and 16% CP for a few weeks, alternating every other day. This approach aimed to minimize sensitivity risk and allow the patient to acclimate to the whitening process gradually. Initially, a less concentrated solution was provided. While further whitening was possible, the result achieved was satisfactory. The appearance of white patches reduced, and the chroma in the highly saturated canines improved to VITA A1-A2, with the central and lateral teeth reaching B1. If composite resin were chosen as the substrate, additional whitening combined with Icon resin infiltration would be necessary.

styleitaliano style italiano bonding veneers indirect anterior restoration whitening

Fig.7
Another view with the shade tabs for comparison is essential. Always consider that the BL shade tabs are more opaque than the Classic tabs, which can influence their perception depending on the lighting environment.

styleitaliano style italiano bonding veneers indirect anterior restoration mock-up

Fig.8
With a secured plan in place, the preparation appointment was ready. Here is the same template transferring the mock-up as a preparation guide for the clinician to cut through.
Articulating paper was used to visualize the main vertical stops on all the teeth. This guided the clinician also to avoid finishing the margins at these crucial landmarks as the clinician was keeping the existing vertical dimension (VD) and maximum intercuspal position (MIP).
Notice the webbing texture. This error occurs if the silicone template has not had all its previous monomers from the previous use fully removed with ethanol. Sterilizing in a bath is only part of the process; dewy monomers still cling onto the fit surfaces of the template and worsen when wetted with water. This is something you might observe more commonly when temporizing crowns/onlays and had to re-temp the same appointment due to an error, and then be presented with this sort of surface defect. Since this was the preparation-guide to cut through and the macro dimensions are correct, the clinician decided to accept it and move on with my appointment.

styleitaliano style italiano bonding veneers indirect anterior restoration depth cut

Fig.9
Using a Round Diamond Bur with a size between 0.8mm-1mm is a great way to outline the margins required. Take note that the bur is used on 2 teeth at the same time at their contact points, sharing the width of the bur. It is the preferred initial depth cut and knowing the final material, in this case Lithium Disilicate, the depths can be adjusted for.

styleitaliano style italiano bonding veneers indirect anterior restoration cord placement

Fig.10
00 Retraction Cord is placed 5-5 in 1 uncut strand to aid the definition of the 2-stage Polyvinyl siloxane (PVS) to come. The black triangles provide a challenge for the path of insertion that is also complicated by a fixed retainer on the palatal surface. For most cases with black triangles, it was preferred to lightly open the contacts with an IPR strip to allow the Light PVS to create uninterrupted surfaces between each tooth and allow the ceramist to form new lobes to create contact. In this case with the orthodontic retention being a high priority, more defined mesial-distal margins are created without breaking the contact is created to allow for a 45-degree path of insertion to camouflage the black triangles whilst lipping over the incisal and cuspal edges.

styleitaliano style italiano bonding veneers indirect anterior restoration Bite used

Fig.11
DMG O-Bite was utilized to capture the patient’s existing vertical dimension and static occlusion. Both molars bilaterally remained untouched, and the VD was maintained. In this instance, I would classify it as a partially conforming case, where the VD and MIP are consistent with the previous state, while intentional adjustments were made to anterior and lateral movements.

styleitaliano style italiano bonding veneers indirect anterior restoration Impression

Fig.12
Despite the advancements and widespread use of intraoral scanners, for anterior veneers and their highly sensitive workflow for both the clinician and the ceramist, I still prefer a 2-Stage PVS technique. I use the recipe of DMG Honigum Pro Putty Soft Fast (purple) combined with Honigum Light Fast (orange). The best demonstration of the definition and tear resistance can be seen in the interproximal arches of silicone encircling the contact points.

styleitaliano style italiano bonding veneers indirect anterior restoration immediate post-op

Fig.13
The top image depicts the immediate post-op after the preparation and temporization with DMG Luxatemp B1. Consideration was given to using BL, but the discussion led to using B1 as the final result subtly boosts the value rather than falling short and appearing warmer than the temporaries. The second image is significant, showing the patient returning for the day of fit with the teeth rehydrated. Just as observed when teeth are whitened or after long sittings under a dam or Optragate, after preparation and temporization, the teeth are truly dehydrated and frosty. This makes their perceived value appear higher than it is, and the chroma often seems reduced. Once rehydrated, a more realistic appearance of the substrate returns. Sometimes, this is useful when observing high chroma abutments and assessing whether the labial reduction created is sufficient as a review between the preparation and fit appointment, influencing the opacity of the chosen restorative material.

styleitaliano style italiano bonding veneers indirect anterior restoration the veneers in varying lights

Fig.14
Lithium Disilicate in MT B1 fabricated with layering to create highlights for a brighter value on the transitioning surfaces. No additional cervical chroma was stained as the minimum thickness in the area would carry the natural substrate through to bring warmth to the region.
Photographing the veneers in different lighting conditions helps the clinician to better appreciate the surface anatomy and internal textures crafted, striking a balance between natural appearance and avoiding exaggeration of halos and mamelons, which can easily be overdone and conflict with the patient’s age.

styleitaliano style italiano bonding veneers indirect anterior restoration

Fig.15
Bonding using DMG LuxaBond Universal, a versatile universal adhesive to complement the Vitique BL resin cement.
Porcelain is sandblasted, etched and silanated. LuxaBond Universal A is mixed with B and applied to teeth. The advantage of this universal bond is there is no need to cure as it is a dual cure bond and thus can be used in cases whereby thin veneers can be cemented without the risk of the cured bond interfering with the fit. All teeth etched, and bonding agent applied in one go with careful clean-up of contact points. Bond is left uncured for seating of the veneers. With the still-wetted microbrush, a swipe on the silanated fit surfaces of the porcelain is used prior applying the Vitique for increased wettability and spread. All veneers seated in one go, working from the mid-line back to allow for the most subtle control of positioning with clean-up with the assistant on each tooth as they are seated.

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styleitaliano style italiano bonding veneers indirect anterior restoration pre-operative occlusal view

Fig.16
Pre-operative occlusal view to show a largely well aligned arch and the palatal fixed retainer that was kept in place.

styleitaliano style italiano bonding veneers indirect anterior restoration post-operative occlusal view

Fig.17
Post-operative occlusal view to observe the finishing line and blend. New buccal silhouette and functioning cusps on the RHS.

styleitaliano style italiano bonding veneers indirect anterior restoration retracted anterior contrastor view

Fig.18
Retracted anterior contrastor view showing the well-managed black triangle that was dominantly present and the symmetry in the buccal corridors achieved.

styleitaliano style italiano bonding veneers indirect anterior restoration final situation

Fig.19
An integrated and natural smile achieved through the workflow outlined. Predictable and reliable bonding of the veneers to enamel surfaces allow for results that can sustain the forces for new cusps to be guided on in function.

styleitaliano style italiano bonding veneers indirect anterior restoration final result

Fig.20
Lateral views to more clearly compare the degree of asymmetrical wear and the results achieved.

Conclusions

It took the first few years of clinical work to appreciate the true strength of a well-bonded restoration. Those instances of cutting off a well-bonded e.max onlay, crown, and veneer revealed its almost-seamless nature with enamel, starkly contrasting with poorly bonded restorations. Over time, it became clear that well-bonded composite or porcelain ages gracefully, much like natural teeth, presenting with chips, sheared surfaces, and crack-lines if traumatized, rather than debonding, leaking, and developing secondary caries. The use of a universal dual cure bond (LuxaBond Universal) provides greater control during tricky cementation steps. Its dual-cure nature allows for safe seating of veneers followed by polymerization with a light source once the position and seating are confirmed, thus improving outcomes and reducing the risk of fracturing thin porcelain shells during cementation. Simplifying workflows and mastering commonly used materials significantly enhances results in real-world practice.

Bibliography

  1. Jurado C, Watanabe H, Tinoco JV, Valenzuela HU, Perez GG, Tsujimoto A. A conservative approach to ceramic veneers: A case report. Operative dentistry. 2020 May 1;45(3):229-34.
  2. Jurado CA, Villalobos-Tinoco J, Tsujimoto A, Castro P, Torrealba Y. The art of minimal tooth reduction for veneer restorations. European journal of general dentistry. 2020 Jan;9(01):45-52.
  3. Levine JB, Finkel S, Jurim A. Anterior Bonded Restorations. Smile Design Integrating Esthetics and Function-E-Book: Smile Design Integrating Esthetics and Function-E-Book. 2015 Oct 30:215.

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